Understanding Bone marrow Transplantation

In bone marrow transplantation, usually 500 to 700 ml of marrow is aspirated from the pelvic bones of a human leukocyte antigen (HLA)–compatible donor (allogeneic) or of the recipient himself during periods of complete remission (autologous). The aspirated marrow is filtered and then infused into the recipient in an attempt to repopulate the patient’s marrow with normal cells.
This procedure has effected long-term, healthy survivals in about half of the patients with severe aplastic anemia. Bone marrow transplantation may also be effective in treating patients with acute leukemia, certain immunodeficiency diseases, and solid-tumor cancers.
Because bone marrow transplantation carries serious risks, it requires strict adherence to infection protection techniques and strict aseptic technique. It also requires that a primary caregiver provide consistent care and continuous monitoring of the patient’s status.

Before bone marrow infusion

• Explain to the patient that the success rate depends on the stage of the disease and on finding an HLA-identical sibling match.
• After bone marrow aspiration is completed under local anesthetic, apply pressure dressings to the donor’s aspiration sites. Observe the sites for bleeding. Relieve pain with an analgesic and ice packs as needed.
• Assess the patient’s understanding of bone marrow transplantation. If necessary, correct any misconceptions about the procedure and provide additional information. Prepare the patient to expect an extended facility stay. Explain that chemotherapy and, possibly, radiation therapy are necessary to remove cells that may cause the body to reject the transplant.
• Various treatment protocols are used. For example, I.V. cyclophosphamide may be used with additional chemotherapeutic agents or total body irradiation to suppress the patient’s immune system and requires aggressive hydration to prevent hemorrhagic cystitis. Control nausea and vomiting with an antiemetic (such as ondansetron, prochlorperazine, or metoclopramide) as needed. Give allopurinol, as prescribed, to prevent hyperuricemia resulting from tumor breakdown products. Because alopecia is a common adverse effect of high-dose cyclophosphamide therapy, encourage the patient to choose a wig or scarf before treatment begins.
• Total body irradiation (in one dose or several daily doses) follows chemotherapy, inducing total marrow aplasia. Warn the patient that cataracts, GI disturbances, and sterility are possible adverse effects.

During bone marrow infusion

• Monitor vital signs every 15 minutes.
• Watch for complications of marrow infusion, such as pulmonary embolus, hypersensitivity reactions, and volume overload.
• Reassure the patient throughout the procedure.

After bone marrow infusion

• Continue to monitor the patient’s vital signs every 15 minutes for 2 hours after infusion, then every 4 hours. Watch for fever and chills, which may be the only signs of infection. Give a prophylactic antibiotic as prescribed. To reduce the possibility of bleeding, don’t administer medications rectally or I.M.
• Administer methotrexate or cyclosporine, as prescribed, to prevent graft-versus-host (GVH) reaction, a potentially fatal complication of allogeneic transplantation. Watch for signs and symptoms of GVH reaction, such as maculopapular rash, pancytopenia, jaundice, joint pain, and anasarca.
• Administer vitamins, steroids, and iron and folic acid supplements, as appropriate. Administration of blood products, such as platelets and packed red blood cells, may also be indicated, depending on the results of daily blood chemistry studies.
• Provide good mouth care every 2 hours. Use hydrogen peroxide and nystatin mouthwash or oral fluconazole, for example, to prevent candidiasis and other mouth infections.
• Also, provide meticulous skin care, paying special attention to pressure points and open sites, such as aspiration and I.V. sites.
• Teach the patient to avoid those with known infection, crowds, and activities associated with increased risk of injury or bleeding (for example, playing contact sports or using a razor blade).